September - 202019Endoscopes have been used as early as the ancient Roman and Greek periods, however, it was in 1805 when Philip Bozzini made the first attempt to examine the urinary tract, rectum and pharynx using a tube that was called Lichtleiter (light guiding instrument). Subsequently in 1853, a French scientist, Antoine Jean Desormeaux gave the name `endoscope' to an instrument that he used to examine the urinary tract. It was in 1960s that a new material called glassfiber was developed in the United States that revolutionized the use of endoscopes. The last few years have seen significant advances in the field of endoscopy. The invent of high definition endoscopes, stents such as lumen apposing metal stents (LAMS) have made endoscopic procedures as the treatment of choice over most complex surgeries that was invariably needed for such medical conditions. We are currently in an era where laparoscopic Heller's myotomy for Achalasia is getting replaced by endoscopic per-oral myotomy (POEM) as first line therapy for achalasia. Some of the most notable technological advances already being used or in development stages in the field of endoscopy areA) Lumen apposing metal stents (LAMS) ­ LAMS represents a new innovation in gastrointestinal endoscopy. These stents have a saddle shaped design and larger inner diameter that theoretically decreases the chances of stent migration. The initial use of LAMS was primarily to drain pancreatic fluid collections and walled off pancreatic necrosis by using 10 mm or 15 mm size LAMS. More recently 20mm size has expanded the use of LAMS to complex procedure ­ endoscopic ultrasound directed transgastric ERCP (EDGE) that enables endoscopic ultrasound (EUS) or endoscopic retrograde cholangiopancreaticography (ERCP) in patients with altered anatomy such as Roux-en-Y-gastric bypass (RYGB). Historically, these patients required surgical approach to perform ERCP. The other off label use of LAMS is to perform drainage of bile by creating connection between common bile duct and intestinal lumen (choledochoduodenostomy) in patients with malignant and unresectable bile duct obstruction after failed ERCP. EUS guided gall bladder drainage by using LAMS is also gaining popularity with encouraging results. More recently LAMS have also been used to create luminal connection between stomach and small bowel (gastrojejunostomy - GJ) in patients with unresectable malignant gastric outlet obstruction. Traditionally, surgical GJ anastomosis was the only option in this patients, however it carried a high morbidity of ~40%. The increasing use of LAMS have shown them to be safe and efficacious. Currently there is one LAMS (Axios, Boston Scientific, TECHNOLOGICAL ADVANCES IN ENDOSCOPYDalbir Sandhu, MD, Director of Endoscopy, Cleveland Clinic Summit Gastroenterology, Assistant Professor of MedicineByCXO Insights
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